HomeMy WebLinkAbout000335.tiff EIORisk
Services'
Northwest Professional Center Renewal Application For
227 US Hwy 206,Suite 302 Business and Management(BAM)
Flanders,NJ 07836-9174 g
Tel:(973)252-5141/(800)689-2550 Indemnity Insurance
Fax:(973)252-5146/(800)689-2839 Non-Profit Organizations
www.ERiskServices.com
email:application@ERiskServices.com
NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE,SUBJECT TO ITS TERMS,APPLIES ONLY TO
ANY CLAIM MADE AGAINST ANY OF THE INSUREDS DURING THE POLICY PERIOD. THE LIMIT OF
LIABILITY AVAILABLE TO PAY DAMAGES OR SETTLEMENTS SHALL BE REDUCED AND MAY BE
EXHAUSTED BY AMOUNTS INCURRED AS COSTS,CHARGES AND EXPENSES(AS DEFINED IN THE
COVERAGE SECTION FOR WHICH APPLICATION IS MADE),AND COSTS,CHARGES AND EXPENSES SHALL
BE APPLIED TO THE RETENTIONS.
General instructions for completing this Application
1. Please type or print in ink.
2. Please read carefully and answer all questions.If a question is not applicable,so state.
3. The Application must be signed by an executive officer.
4. This Application and all exhibits shall be held in confidence.
5. Please read the Policy for which application is made(the"Policy")prior to completing this Application.
6. The terms as used herein shall have the meanings as defined in the Policy.
I. General Information
1. Name of Organization: Weld County Housing Authority
Address: 1150 O Street
(Number) (Street)
Greeley CO 80631
(City) (State) (Zip Code)
2. Internal Revenue Service Code:
3. Nature of Operations: Housing Authority
4. Has the Organization been in operation longer than three(3)years? ®Yes ❑No
5 Is the Organization involved in my labor/union negotiations or collective bargaining activities? ❑Yes ®No
(10-09) Page 1 of 4
II. False Information
NOTICE TO ARKANSAS APPLICANTS:Any person who knowingly presents a false or fraudulent Claim for payment
for a Loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
NOTICE TO COLORADO APPLICANTS:It is unlawful to knowingly provide false,incomplete,or misleading facts or
information to an insurance company for the purpose of defrauding or attempting to defraud the company.Penalties may
include imprisonment,fines,denial of insurance and civil damages.Any insurance company or agent of an insurance company
who knowingly provides false,incomplete,or misleading facts or information to a policyholder or Claimant for the purpose of
defrauding or attempting to defraud the policyholder or Claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS:WARNING:it is a crime to provide false or misleading
information to an Insurer for the purpose of defrauding the Insurer or any other person.Penalties include imprisonment
and/or fines.In addition,an Insurer may deny insurance benefits if false information materially related to a Claim was
provided by the applicant.
NOTICE TO FLORIDA APPLICANTS:Any person who knowingly,and with intent to injure,defraud,or deceive any
Insurer files a statement of Claim or an application containing any false,incomplete or misleading information is guilty of a
felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For you protection,Hawaii law requires you to be informed that presenting a
fraudulent Claim for payment of a Loss or benefit is a crime punishable by fines or imprisonment,or both.
NOTICE TO KENTUCKY APPLICANTS:Any person who knowingly and with intent to defraud any insurance company
or other person files an application for insurance containing any materially false information,or conceals,for the purpose of
misleading,information concerning any fact material thereto,commits a fraudulent insurance act,which is a crime.
NOTICE TO LOUISIANA APPLICANTS:Any person who knowingly presents a false or fraudulent Claim for payment of
a Loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to fines and confinement in prison.
NOTICE TO MAINE APPLICANTS:It is a crime to knowingly provide false,incomplete or misleading information to an
insurance company for the purposes of defrauding the company.Penalties may include imprisonment,fines or a denial of
insurance benefits.
NOTICE TO MINNESOTA APPLICANTS:A person who submits an application or files a Claim with intent to defraud or
helps commit a fraud against an Insurer is guilty of a crime.
NOTICE TO NEW JERSEY APPLICANTS:Any person who includes any false or misleading information on an
Application for an insurance policy is subject to criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS:Any person who knowingly presents a false or fraudulent Claim for payment
of a Loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be
subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS:Any person who knowingly and with intent to defraud any insurance company
or other person files an application for commercial insurance or a statement of Claim for any commercial or personal
insurance benefits containing any materially false information,or conceals for the purpose of misleading,information
concerning any fact material thereto,and any person who,in connection with such application or claim,knowingly makes or
knowingly assists,abets,solicits or conspires with another to make a false report of the theft,destruction,damage or
conversion of any motor vehicle to a law enforcement agency,the department of motor vehicles or an insurance company
commits a fraudulent insurance act,which is a crime,and shall also be subject to a civil penalty not to exceed five thousand
dollars and the value of the subject motor vehicle or stated Claim for each violation.
NOTICE TO OHIO APPLICANTS:Any person who,with the intent to defraud or knowing that he is facilitating a fraud
against an Insurer,submits an application or files a Claim containing a false or deceptive statement is guilty of insurance
fraud.
t10-09) Page 2 of 4
NOTICE TO OKLAHOMA APPLICANTS:WARNING:Any person who knowingly,and with intent to injure,defraud,or
deceive any Insurer,makes any Claim for the proceeds of an insurance policy containing any false,incomplete or misleading
information is guilty of a felony.
NOTICE TO PENNSYLVANIA APPLICANTS:Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of Claim containing any materially false information,
or conceals for the purpose of misleading,information conceming any fact material thereto commits a fraudulent insurance act,
which is a crime and subjects such person to criminal and civil penalties.
NOTICE TO TENNESSEE&VIRGINIA APPLICANTS:It is a crime to knowingly provide false,incomplete or
misleading information to an insurance company for the purpose of defrauding the company.Penalties include imprisonment,
fines and denial of insurance benefits.
NOTICE TO WASHINGTON APPLICANTS:It is a crime to knowingly provide false,incomplete,or misleading
information to an insurance company for the purposes of defrauding the company.Penalties include imprisonment,fines,and
denial of insurance benefits.
III. Other Information
I. The undersigned declares that to the best of his/her knowledge the statements herein are true.Signing of this Application
does not bind the undersigned to complete the insurance,but it is agreed that this Application shall be the basis of the
contract should a Policy be issued,and this Application will be attached to and become a part of such Policy,if issued.
Insurer hereby are authorized to make any investigation and inquiry in connection with this Application as they may deem
necessary.
2. It is warranted that the particulars and statements contained in the Application for the proposed Policy and any materials
submitted herewith(which shall be retained on files by Insurer and which shall be deemed attached hereto,as if physically
attached hereto),are the basis for the proposed Policy and are to be considered as incorporated into and constituting a part
of the proposed Policy.
3. It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the
effective date of the Policy,the applicant will notify Insurer and,at the sole discretion of Insurer,any outstanding
quotations may be modified or withdrawn.
4. It is agreed that in the event there is any misstatement or untruth in the answers to the questions contained herein,Insurer
have the right to exclude from coverage any claim based upon,arising out of or in connection with such misstatement or
untruth.
Signed: Date; 7/13/2022
(must a fined by an Executive Officer of the Parent Organization)
For purposes of creating a binding contract of insurance by this application or in determining the rights and
obligations under such contract in any court of law,the parties acknowledge that a signature reproduced by either
facsimile or photocopy shall have the same force and effect as an original signature and that the original and any such
copies shall be deemed one and the same document.
Please fully complete and attach the Information for the Coverage
Section(s)desired.
(10-09) Page 3 of 4
Employment Practices Coverage Section Information
Is the Organization seeking Employment Practices coverage?If yes,please answer the following ®Yes ❑No
questions.
1. Total number of Employees(full-time and part-time)
0to 5 51 to 75
6 to 10 76 to 100
X 111o15 101 to 200
16 to 25 201 to 300
26 to 50 Exact number,if over 300
Note: When answering the above range of Employees,multiply the number of pail-lime Employees by a factor of.5 and add to
number of full-time Employees.
2. Does the Organization anticipate in the next 12 months,or has the Organization
transacted in the last 12 months,any consolidations or layoffs affecting 35%or more of the
Employees of the Organization? ❑Yes ®No
3. Describe the internal controls the Organization maintains for Employment Practices.
a) Does the Organization publish and distribute an employee handbook to every
Employee? ®Yes ❑No
b) Are there written procedures for handling Employee complaints of discrimination
or sexual harassment? ®Yes ❑No
c) Are there written procedures for handling Employee grievances or complaints? ®Yes ❑No
Insured Person and Organization Coverage Section Information
Is the Organization seeking Insured Person and Organization coverage?If yes,please answer
the following questions. ❑Yes ®No
1. Describe the following financial information of the Organization for the most recent fiscal year-end.
a) Total Assets $0 to 2,000,000 $15,000,001 to 20,000,000
X $2,000,001 to 5,000,000 over$20,000,000
$5,000,001 to 7,500,000
___ $7,500,001 to 10,000,000 Exact amount,if over$20,000,000
$10,000,001 to 15,000,000
b) Does the Organization have a negative fund balance? ❑Yes ®No
If yes,please provide complete financial statements
2. Number of for-profit Subsidiaries the Organization owns: x 0 1 Exact number if more than 1
3. Are the annual revenues for the Subsidiaries referenced above greater than$250,000? ❑Yes ®No
If yes,please provide complete financial details.
4. Does the Organization render any professional services for others for a fee or
compensation?If yes,please provide details on a separate page. ❑Yes ®No
Fiduciary Coverage Section Information
Is the Organization seeking Fiduciary coverage?If yes,please answer the following questions. ❑Yes ®No
1. Does the Organization maintain any employee benefit or pension plan for its
Employees under the Employee Retirement Income Securities Act of 1974? ❑Yes ®No
2. Are the total plan assets for the plans referenced above greater than$1,000,000? ❑Yes ❑No
If yes,please provide complete details regarding the plans.
(10 09) Page 4 of 4
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